This blog post was made a while back, from time-to-time I will republish them with associated comments that resulted. This topic is about “rest” after the injury. Most if not all medical professionals now prescribe this method, but as we found out in Zurich recently, the research behind exactly what “rest” is and for how long is unknown. What is known allowing the brain to settle down for a period of time is highly beneficial.
Although most point to physical rest as the major component of concussion management the truth of the matter is that all activity that affects brain activity needs to be limited after a concussion. If we use the “snow globe” analogy; all the flakes in the globe must come to rest before exposing it to further activity. What excites the “flakes” or brain, honestly, just waking up does this. That is why I have been hammering on the need for COMPLETE rest after a concussive episode. It is also why I am a firm believer in getting kids out of school while the brain injury heals.
This information is not new to you that read the blog, but it seems that this management technique is just catching on as a principal protocol, rather than using it if there are setbacks;
“There is so little we really know about concussions,” said Dr. Mary Dombovy, vice president of Unity Neurosciences, which includes physical medicine and rehabilitation, neurology and neurosurgery. “We’re learning more as time goes by. What we’re learning is it’s not just physical exertion that is making the brain work harder. School tasks, studying for tests, trying to write a paper, these things are very stressful for people who’ve had a concussion.”
It is not that it is stressful, per se, it is that the brain is FUNCTIONING to do those tasks and like getting on crutches for a broken leg, the only way to get the brain on “crutches” is to not give it any stimulation. Along with that comes how long and what to do when symptoms have gone, to me it is obvious that this is where you then begin the Zurich RTP protocol (the current concussion management protocol I use).
What I am having a hard time fathoming is that doctors are now just figuring out that rest is key, and comments like this from a doctor just work to confuse everyone;
“The science is not quite to the point where we can think of an antibiotic to treat pneumonia,” said Dr. Jeff Bazarian, associate professor of Emergency Medicine, Neurology, Neurosurgery at the University of Rochester Medical Center. He specializes in concussions.
“It looks like it’s helpful, but if you don’t do it, does it cause injury? We don’t know. … Are you doing some kind of damage to the brain when you don’t rest, or just not getting better quick?”
Without the results of clinical trials to guide them, doctors err on the side of caution and recommend cognitive rest.
“There’s lots of evidence it’s a good idea,” said Bazarian, noting that symptoms can return if the brain doesn’t have time to heal.
Maybe I am wrong here, but yes you can do damage to the brain when you are not resting it, especially when the brain is still in the traumatic phase of the cascade. Am I missing something here?
Even if it is “conservative”, cognitive rest can only help an injured brain. With pre-teens and adolescents getting them off the technology, especially the video games, will allow the brain to begin the important process of healing, at the very least it will not delay symptom recovery.
I think what Dr. Bazarian was saying is that the science behind what happens with a concussion, at the cellular level, is fairly recent science. What has not been completely determined is the healing process behind this cellular damage. Rather then a broken leg, as you mentioned, lets look at it like a sprained ankle. Years ago, treatment for a sprained ankle was complete rest, non-weight-bearing for a prolonged period of time. As the science improved, we started to understand that a brief period of rest might be beneficial, depending on the severity, but then early ROM activities and protected weight bearing actually improved the healing process.
With concussion, we are still too early in the science to know what is the best way to rehabilitate from this injury. We know that a second injury too early in the healing process can have fatal sequelae. But does ADL’s cause more injury at the cellular level? We do not know. It can cause an increase in symptoms, just like jogging too early on a sprained ankle will cause more pain. But if you stop jogging and go back to walking, does that delay healing or cause more damage? Probably not. I think the same will likely come out of the research on healing from a concussion.
We also know that not all concussions are the same, just like ankle sprains. My recommendation is that if an activity increases your symptoms, then avoid that activity for several days. Very much like the stepwise increase in physical activity with the RTP protocol. Some kids are going to need to stay home from school and avoid most types of stimulation. If symptoms are not worsened by school or homework or limited screen exposure, then I think it is hard to argue that these activities could be harming them. I can actually envision a time when, as part of the rehabilitation process, they are instructed to do some cognitive activities.
My Reply to Dr. Benford:
I can see all of that Dr. Benford…
My case is that complete rest for every concussion is beneficial… I also agree as the sequale progresses there will be a need for such things, ‘Wiiabilitation’ if you will…
Even if we were to adopt the principles from orthopedic injuries the effusion phase is roughly 72 hours, why not approach concussions in the same manner until it becomes very clear… Even the most innocent sprained ankle benefits from complete rest for a short time (even if it is just sleeping ~8 hours)… The brain in my personal ans professional experiences needs AT THE LEAST double that…
I guess what I am adamant about is the need to not only rest but remove any possible external factors that could prolong recovery… Perhaps it is a bit conservative and each case warrants a different approach, but promoting rest certainly, in my mind, would be not only prudent but proactive…
Some thoughts on rest– as the brain influences physical, cognitive and emotional responses
3 Essential Components of Rest: Physical, Cognitive, and Emotional.
Because the brain influences physical, cognitive, and emotional aspects of an individual, it seems logical and essential that ALL 3 COMPONENTS of REST are incorporated into a SRC management framework.
Wrightson and Gronwall (1999), pioneer clinicians in the area of SRC, perceived Rest as an essential component of the treatment process. They emphasized the importance of learning to pace oneself, and subsequently rest in order to avoid fatigue and a subsequent return of symptoms, and to further enhance functional recovery..
Individual accommodations: RTP. RTS, employment, social activities
Physical, cognitive, and emotional caution
should be exercised for the injured student. The student component of the student-athlete should be prioritized over the athlete component: The student’s performance within the classroom setting should return to normal before engaging in any athletic related activities. Pressures to prematurely return to and succeed on the athletic field, in school, in part-time employment, and in socializing must be minimized.
May I suggest that interested readers click on the below noted link found under Management on your website for expansive and relevant info on this SRC topic.
Sport-Related Concussion, NASP (Don and Flo Brady)
In addition, for those interested in SRC history…suggest you read some of Gronwall and colleagues 1900′s writings on topics such as REST and the cumulative effects of concussions
Gronwall, D. (1989). Cumulative and persisting effects of concussion on attention and cognition. In H. S. Levin, H. M. Eisenberg, & A. L. Benton (Eds.), Mild head injury (pp. 153–162). New York, NY: Oxford University Press.
Gronwall, D., (1991). Minor head injury. Neuropsychology, 5, 253–265.
Gronwall, D., & Wrightson, P. (1975). Cumulative effect of concussion. The Lancet, 2, 995–997.